Nursing Education Interventions for Managing Acute Pain in Hospital Settings

A Systematic Review of Clinical Outcomes and Teaching Methods

Gareth Drake, DClinPsy; Amanda C. de C. Williams, PhD, CPsychol


Pain Manag Nurs. 2017;18(1):3-15. 

In This Article

Abstract and Introduction


The objective of this review was to examine the effects of nursing education interventions on clinical outcomes for acute pain management in hospital settings, relating interventions to health care behavior change theory. Three databases were searched for nursing education interventions from 2002 to 2015 in acute hospital settings with clinical outcomes reported. Methodological quality was rated as strong, moderate, or weak using the Effective Public Health Practice Project Quality Assessment Tool for quantitative studies. The 12 eligible studies used varied didactic and interactive teaching methods. Several studies had weaknesses attributable to selection biases, uncontrolled confounders, and lack of blinding of outcome assessors. No studies made reference to behavior change theory in their design. Eight of the 12 studies investigated nursing documentation of pain assessment as the main outcome, with the majority reporting positive effects of education interventions on nursing pain assessment. Of the remaining studies, two reported mixed findings on patient self-report of pain scores as the key measure, one reported improvements in patient satisfaction with pain management after a nursing intervention, and one study found an increase in nurses' delivery of a relaxation treatment following an intervention. Improvements in design and evaluation of nursing education interventions are suggested, drawing on behavior change theory and emphasizing the relational, contextual, and emotionally demanding nature of nursing pain management in hospital settings.


Despite the designation of pain as "the fifth vital sign" (International Pain Summit, 2011), acute pain remains variably and often suboptimally managed (Apfelbaum, Chen, Mehta, & Gan, 2003; Duncan et al., 2014). Poor acute pain management can lead to adverse consequences including postsurgical complications and prolonged hospital stays, increasing health care costs (Mackintosh, 2007; Sinatra, 2010), and patient suffering (IASP, 2010; Kehlet, Jensen, & Woolf, 2006).

Nurses' key role in inpatient pain management (Bucknall, Manias, & Botti, 2007) can extend to responsibility for pain assessment, basic analgesic prescription, and titration of patient-controlled analgesia (National Health Service, 2015). Many of these responsibilities are covered by guidelines on best practice in assessment and treatment (McCafferty & Pasero, 1999). Assessment is ideally by patient report (McCaffery & Pasero, 1999; Turk & Melzack, 2011), but nurses may fail to assess pain adequately (Sloman, Rosen, Rom, & Shir, 2005) and/or may substitute their own estimates of pain (Schafheutle, Cantrill, & Noyce, 2001). Treatment may be undermined by excessive fears of unwanted analgesic effects and by inadequate appreciation of pharmacological and nonpharmacological resources to reduce patient distress (Lui, So, & Fong, 2008; Sloman et al., 2005).

Shortcomings in pain education during nursing training (Chow & Chan, 2014) underlie poor postqualification pain management. An institutional needs assessment that aimed to improve postsurgical pain management found important skills deficits, particularly in nurses' ability to recognize signs and symptoms of pain (González-Fernández et al., 2014).

Many inpatient pain initiatives have relied on education to improve nurse knowledge and beliefs (Gordon, Pellino, Enloe, & Foley, 2000; Gunnarsdóttir & Gretarsdottir, 2011; Kaasalainen et al., 2014; McNamara, Harmon, & Saunders, 2012), but these do not necessarily predict clinical behavior (Watt-Watson, 2001), for which self-report lacks accuracy (Dihle, Bjolseth, & Helseth, 2006). There is no simple way of improving clinical practice (Oxman, Thomson, Davis, & Haynes, 1995), but effective training involves interactive learning (Forsetlund et al., 2009; Twycross, 2002) and individual feedback (Forsetlund et al., 2009; Gunnarsdóttir & Gretarsdottir, 2011).

Psychological theory informing behavior change has been synthesized by Michie et al. (2005) to use in designing evidence-based health care guidelines. Twelve domains, including knowledge and skills, motivational factors, learning context, beliefs about capabilities, and the perceived role of the learner map on to existing constructs from the research literature (Fishbein, Triandis, Kanfer, Becker, & Middlestadt, 2001). These domains can also be used to develop behavior change techniques (Michie, Johnston, Francis, Hardeman, & Eccles, 2008), and applying them to nurse education in pain management may enable better distinction of helpful from unhelpful findings and guiding theory (Gunnarsdóttir & Gretarsdottir, 2011; Twycross, 2002).

We examined the effect on clinical outcomes of nurse education interventions for acute inpatient pain management and the use of underlying theory in intervention design:

  1. What types of nursing education interventions have been implemented to improve pain management in hospital settings?

  2. Do nursing education interventions to improve pain management yield positive clinical outcomes?

  3. Do the teaching methods used in the nursing interventions correspond to existing behavior change domains?